About Trigger Points

WHAT IS A TRIGGER POINT? A trigger point is a highly sensitive nodule in an unusually taut band of skeletal muscle. It normally occurs near the middle of the fiber at the motor end plate junction (where the motor nerve contacts the muscle). This nodule is a knot of contracted sarcomeres, that is, an area where many sarcomeres bunch closely together, leaving the sarcomeres in the rest of the fiber stretched out, which causes the tension. Although trigger point may not initially strike the reader as a term of science, the condition is now well! characteri"ed and the term is accepted in medical te#ts.

TRIGGER POINT FEATURES. $AI%&'( A%) )*+*$TI,*, -'T .*(ATI,*(/ *A0/ T1 T.*AT. This special condition of muscle tissue causes a great number of people a great deal of pain. 'nfortunately trigger points remain unnoticed unless the e#aminer is aware and specifically looking for them. They deceive in part because they are hidden from easy observation. (2achines in a typical doctor3s office can3t detect them.) They also deceive because the pain they cause is most often felt at another location. $ain perceived at a distance from its actual source is known as referred pain . -ut once trigger points are located (usually through range of motion testing and palpation) they are amenable to treatment through relatively simple procedures, such as manual pressure, speciali"ed stretch techni4ues, acupuncture!style needling, and injection. $AI% .*&*..A(. 567 of trigger points refer pain to another location in the body. *ach trigger point produces a characteristic pattern of referred pain, that is, a pattern generally unlike one produced by trigger points in other muscles, or even trigger points in other fibers in the same muscle. Accordingly, knowledge of muscles3 typical pain referral patterns helps greatly in determining which muscle, and sometimes even which part of a muscle, is involved. .*0T.I+TI1% 1& 21TI1% A%) $10T'.*. -eside creating referred pain, the other key action of trigger points is to restrict the length to which the affected muscle can e#tend. This means that the motion of that part of the body becomes restricted or stiff . Thus a trigger point in the left levator scapula muscle can prevent the neck from turning very far to the right. In severe cases the neck becomes immobili"ed. Trigger points in certain fibers of the gluteus ma#imus muscle can prevent the individual from bending over very far at the hip, and, in addition to causing hip pain, may cause a distortion of posture in which the hip becomes rotated backward. Any part of the body can stiffen and lose its mobility because of trigger points. 1T8*. 0/2$T120. 0ometimes trigger points causes paresthesia (numbness, tingling or a burning sensation). +ertain trigger points can cause di""iness and unsteadiness rather than pain, which is especially detrimental to the elderly. +1%&I.2I%9 0I9%0. )irect pressure on a trigger point often recreates pain that the subject identifies as 3their pain3. This reaction confirms the relevance of that point. 2anual plucking of the taut band of muscle in which the trigger point lies often produces a local twitch response, which provides another useful confirmation. :*/ A%) 0AT*((IT* T.I99*. $1I%T0. Trigger points can influence each other and have dependency relationships. In other words they are sometimes arranged in hierarchies in which some, which are called key trigger points, cause or perpetuate others, which are called

satellite trigger points. In this situation the clinical picture is more comple#. 0ometimes, for e#ample, disabling a key trigger point will simultaneously disable dependent satellite trigger points that have been causing additional pain according to their own referral patterns. 1n the other hand, treating only a satellite trigger point may bring no lasting relief as long as an undiscovered key trigger point in some other muscle keeps reactivating it.

TRIGGER POINTS ARE NOT IMAGINARY. The reality of trigger points is evident to anyone who has had pain 4uickly relieved by a simple trigger point treatment. &or skeptics !! which means most people who3ve never had such treatment !! the reality of trigger points has been demonstrated by sensitive instruments that can photograph the abnormal structure of the muscle at the trigger point, and instruments capable of measuring their unusual biochemical and micro! electrical signatures. &or e#ample, Travell and 0imons (;<<<= ><) provide a microscopic photograph of a trigger point from dog muscle that clearly shows the sarcomeres all bunched up at that point. In another e#ample, ?ay 0hah, working with colleagues at the %ational Institutes of 8ealth, developed a techni4ue using tiny pipettes by which he was able to get tissue samples from trigger points in living people and compare them to those from normal muscle tissue in the same people. The trigger points samples showed lower $8 and significantly greater concentrations of several biochemicals important in the chemistry of pain, namely substance $, bradykinin, serotonin, norepinephrine, tumor necrosis factor, interleukin!;@ and calcitonin gene! related peptide (0hah et.al. ABBC). In sum, both microscopic photographs and biochemical assays have documented the unusual structure and chemical makeup of the trigger point as compared to normal muscle tissue. $eople who may have been told for years that their pain was just in their head (psychosomatic) now have rigorous evidence that trigger points e#ist. Top of $age 812*

This page is part of a larger website intended to educate people about trigger point bodywork and other methods of non-invasive, drug-free pain relief. Myofascial therapy was developed by physicians in the last few decades. Its primary purpose is to eliminate myofascial pain, but it also improves movement and posture. I offer myofascial treatment and other pain management services in the Millburn, Livingston, Bloomfield and edar !rove area of northern "#. If you live in a town such as !len $idge, lifton, Little %alls, or %airfield, "# I would still be the closest certified therapist. Maplewood, Livingston, $oseland and Totowa also fall into this category, as do Mountain &iew, 'reakness, (est and )outh *range, "# and much of the rest of "ew #ersey. &erona, +sse, %ells and Montclair and aldwell "# of course are in the immediate vicinity. If you live elsewhere you may be able to find a practitioner nearby.

Stiffness from !tent Trigger Points

Trigger points can be latent or active. An active trigger point causes pain and restricts motion. This pain may be merely annoying, or it may be severe, e#cruciating, debilitating, or even paraly"ing. A latent trigger point restricts the range of motion of the affected muscle but does not cause pain within this restricted range. This restricted motion is usually e#perienced as stiffness. (atent trigger points are painful when directly pressed. T8* -A) %*D0 about latent trigger points is that, over time, they create uncomfortable postural distortions !! such as rounded, hunched or uneven shoulders, protruding head, abnormal curvature of the spine, twisted hips, rotated sacrum, functional lower leg length ine4uality, e#cessive pronation of the feet, etc. These effects result from the individual unconsciously trying to avoid pain= over time he or she builds postural and movement habits that avoid bringing the muscle beyond it3s restricted range, which is painful. In this way latent trigger points become the source of dysfunctional posture that seems impossible to change. They are the source of much of the decrepitude and discomfort of old age, for we tend to accumulate latent trigger points as we get older. 0imilarly, athletes and dancers who try to stretch out stubborn restrictions in movement are usually unknowingly wrestling with latent trigger points. T8* 911) %*D0 is that latent trigger points can be cleared up just like active trigger points. Dith careful and accurate therapy posture improves and ease of movement returns !! without forcing stretches that may be too painful to bear. This aspect of trigger point therapy is obviously important for older people who may think they are doomed to shuffling around, or for anyone with signs of incipient decrepitude. It is also useful for younger people, especially dancers and atheletes, 4uite apart from any pain condition, because movement becomes more fluid.

W"!t #!uses Trigger Points?

THERE ARE SE$ERA #AUSES of trigger points. These include direct trauma (an accident or injury), unusual e#ertion and repetitive strain. )irect trauma involves impact, as from a fall, or an automobile or skiing accident. 'nusual e#ertion results from sudden effort, such as picking up a heavy bo#, or pulling hard on something that is stuck. .epetitive strain trigger points, on the other hand, come from less intense use (or misuse) of a muscle that adds up over time. *#amples include habitually reading in a position that stresses the neck muscles, holding a musical instrument imperfectly, habitually slumping over a computer, or bending over to cut hair all day. The repetitive strain category also includes abnormalities in the skeleton that activate certain muscles inappropriately, such leg length ine4uality or 2orton3s &oot.

#OM%INATIONS OF #AUSES. Trigger points fre4uently arise from a combination of these causes. A person may have a whiplash injury from a car accident (trauma) and then, months or years later, develop terrible headaches following e#cessive work at the computer (repetitive

strain). An initial injury, in other words, can set the stage, making the person more prone to develop trigger points from later stresses.

SYSTEMI# #ONTRI%UTING FA#TORS. 9reat emotional stress, inade4uate nutrition, infections and endocrine system imbalances are other factors known to encourage development of trigger points, and to perpetuate them once they are established (Travell and 0imons ;<<<= ,;=+h.E).

ENHAN#E& PAIN. If left untreated some trigger points set off changes in the spinal cord that enhance the original pain. In these instances the feedback loop that normally dampens escalating pain gets broken (0hah ABB6).

Ho' #ommon is Trigger Point P!in?

In the ;<<< *dition of Myofascial 'ain and -ysfunction )rs. Travell and 0imons review studies of the prevalence of pain induced by trigger points, which they term myofascial pain . 0ome were studies of people who visited medical practices, and others of various people in the general population not seeking medical attention. The incidence of trigger points in both kinds of group was higher than one might e#pect.

STU&IES OF PEOP E SEE(ING ME&I#A ATTENTION FOR PAIN (;) A neurologist e#amining <> patients from a community pain medical center found that <C7 had at least part of their pain caused by myofascial Tr$s, and in FE7 myofascial Tr$s were considered the primary cause of the pain. (,ol.;=;C). (A) Among A5C consecutive admissions to a comprehensive pain center, a primary organic diagnosis of myofascial syndrome was assigned in 567 of cases. A neurosurgeon and a physiatrist made this diagnosis independently, based upon physical e#amination 3as described of 0imons and Travell3 . (,ol.;=;C). (C) &ive lumbogluteal muscles of <F> patients complaining of pain in the locomotor system were e#amined in an orthopedic clinic. &orty!nine percent of the patients presented with latent Tr$s and A;7 presented with active Tr$s in the piriformis muscle. (,ol.;=;C).

STU&IES OF PEOP E NOT SEE(ING ME&I#A ATTENTION

)o people not in doctor3s offices have trigger points tooG (E) In one study cited by Travell and 0imons, A>< student nurses were e#amined for the presence of trigger points in various jaw and neck muscles. In the four different jaw muscles tested trigger points were found in 6E7, E67, EC7 and EB7 of the individuals. In the three neck muscles e#amined trigger points were found in C67, CC7 and EA7 of them. (This study did not distinguish latent from active trigger points, but Travell and 0imons note that some were probably active because some individuals had pain in the referral areas.) (6) In another study of five lower back and hip muscles in ;BB asymptomatic individuals, latent trigger points were found in a high percentage= 4uadratus lumborum E67, gluteus medius E;7, iliopsoas AE7, gluteus minimus ;;7, piriformis 67. (>) /et another study considered the age of patients with fibrositis syndromeH . Travell and 0imons note that The greatest number were between C; and 6B years of age. These data agree wtih our clinical impression that individuals in their mature years of ma#imum activity are most likely to suffer from the pain syndromes of active myofascial Tr$s. Dith the reduced activity of more advanced age, the stiffness and restricted range of motion of latent Tr$s tend to become more prominent than the pain of active Tr$s. (,ol.;=;E). /ounger people also have trigger points that can cause debilitating pain. These cases are more likely to be caused by a specific traumatic incident, such as a car accident or twisting the neck the wrong way while making some muscular effort. As people age they tend to accumulate latent trigger points left over from the various insults that an active life visits on the body. Then when new trauma occurs, or repetitive strain builds up, they are much more suspectible to a trigger point that can cause serious and perhaps long!lasting pain.

H &I-.10ITI0= Travell and 0imons consider the term fibrositis An outmoded term with multiple meanings. 2any authors in the past used it to identify what were myofascial trigger points. 1ther authors have used the term very differently.... De avoid using the term because of its ambiguity. 1ne of the problems that historically kept medical science from systemati"ing knowledge about trigger point pain was the proliferation of terms for the condition. Top of $age 812*

Wi)) Trigger Point T"er!*+ He)* 'it" +our P!in?

A #OMMON SOUR#E OF PAIN. 2odern medicine has many important results to its credit and I am an admirer. -ut many people have had pain that couldnIt be resolved by their doctor or chiropractor. Dhile pain from inflamation is often treated successfully with ibuprofen and related drugs, many common pains are not inflammations. .ather their source is a condition in muscle

tissue known as a trigger point. Trigger points can be treated by manual therapies that don3t re4uire drugs, surgery, or injections. ($hysicians can resolve trigger points by injection if they know how to locate them.)

TYPES OF PAIN. Trigger point therapy is effective for a great variety of pains, but not all. 8ere are some markers that help distinguish trigger point pain= !! If pain is from a specific incident or has built up over time (and is not in the gut), trigger point therapy will probably help. !! Trigger point pain is usually of the dull aching variety rather than stabbing or throbbing. 0ome trigger point pain, however, is stabbing, as lower back pain from trigger points in the 4uadratus lumborum can be, or neck pain from twisting the head when there are trigger points in the levator scapulae. In the event of throbbing pain one should see a physician. !! Trigger point pain entails less freedom of movement in the part of the body which is affected. !! $ain from trigger points generally increases when you strain the involved muscle. Thus it often gets worse as the day goes on. -ut note that sleeping in certain positions also puts stress on important muscles. Therefore trigger points can cause you to wake up too early, or wake up with a backache, pain in your neck, etc. !! If the pain is accompanied by swelling or redness you should consult a physician, not a trigger point therapist. !! If the pain is accompanied by tingling sensations it would be logical to think of a neurologist, but trigger point therapy can often help in these cases too. &or e#ample, unusually taut muscles caused by trigger points can pinch nerves. And, as noted in the 1ther 0ymptoms section in the About Trigger $oints page, trigger points in some muscles do cause numbness, tingling and even burning sensations. 8eadaches, even ones you3ve had for ;B or AB years, can usually be treated effectively with trigger point techni4ues. 8eadache treatments alone would be enough to make all the work and research that has gone into developing trigger point therapy worthwhile. -ut on the other hand, trigger point treatments for low back pain, hip pain, shoulder or neck pain would also make all this research more than worthwhile. The list is long.

EFFE#TI$E THERAPY FOR SE$ERE PAIN. Trigger point pain, whether referred elsewhere or not, can be severe J so severe that a person bends over and canIt straighten up, so severe that he or she canIt walk or type. In e#treme cases trigger point pain has led people to consider suicide. -ut despite the occasional severity of trigger point pain, despite that fact that many people may have endured it for years, it is usually not difficult to treat by a skilled practitioner using one or more manual techni4ues.

TRIGGER POINT THERAPY USUA Y WOR(S ,%UT NOT A WAYS-. $eople can suffer a great deal of pain following candida and other infections, cancers, organ dysfunctions, allergies, metabolic disorders, and other systemic conditions. Dhen such conditions are present

myofascial trigger point therapy can often help (because myofascial pain is part of the overall picture), but does not offer to cure the underlying condition. A good trigger point therapist can usually !! though not always !! make the patient more comfortable (but sometimes not even that.) These caveats being stated, it3s fair to say that trigger point therapists substantially help most people who come to them. Although non!physician trigger point therapists cannot resolve serious medical problems, what they can do, and what they are especially good at, is relieving pain that seems to have no identifiable medical cause. 1ften they succeed in getting rid of pain endured for years that has not yielded to a variety of medical specialities. &or the treatment to take full effect patients often need to take action themselves, for e#ample, doing recommended stretches or improving posture during certain activities. All trigger point therapists I have talked to report occasionally achieving total relief for seemingly difficult pain !! pain perhaps endured for months !! in just one treatment. I3ve certainly seen this happen in my practice. -ut in most cases several treatments are re4uired.

FAST. SAFE AN& &IAGNOSTI#. Trigger point therapy usually gives at least partial relief 4uickly, surprising most patients. This means that both therapist and patient understand early on whether further trigger point work is appropriate. This knowledge can save time, money and worry. In addition to its 4uick action, trigger point therapy won3t harm you (when done by a properly trained practitioner). This outstanding safety profile is an important feature of trigger point therapy. Top of $age 812*

Ho' &oes Trigger Point T"er!*+ Wor/?

#OMPONENTS OF TRIGGER POINT THERAPY. Trigger point therapy, as practiced by +ertified 2yofascial Trigger $oint Therapists, has three basic tasks. *ach component can be simple or comple#= ;. (ocate the trigger points causing the patient3s pain andKor other symptom. A. *liminate these trigger points. C. 8elp eliminate perpetuating factors. This means determining if the patient has habits that are perpetuating his trigger points and counseling him or her how to change or improve them.

0.

O#ATING TRIGGER POINTS.

&.12 T8* $AI% .*&*..A( $ATT*.%. *#pensive scanning and testing e4uipment is of little use in locating the trigger points causing the pain problem. The necessary detective work is accomplished with direct observation and testing. The most important indicator is the pain pattern itself. As noted in the section on trigger point characteristics, each muscle trigger point location has a characteristic pain referral pattern. &1. *LA2$(*, if the patient has a severe headache behind the eyes it is probably caused by a trigger point in the sternal division of the sternocleidomastoid muscle. (ess commonly, it could be caused by a trigger point in the temporalis muscle, one in the upper portion of the splenius cervicis muscle, or even from one in the masseter, the suboccipitals or a couple other muscles. 'nless you are an orthopedist or physical therapist this list of muscles that can refer pain behind the eye may sound overly technical and boring. That3s because good trigger point work, though not boring, is technical. (ocating trigger points re4uires precise knowledge of anatomy and the pain referral patterns.

&.12 .A%9* 1& 21TI1%. The second method used to track down the source of pain is range of motion testing. As noted in the section on trigger point characteristics, a trigger point prevents the full e#tension of the affected muscle. Arranging the patient3s body in specific postures, the therapist tests the range of motion of the various muscles that are likely to be involved and notes which which ones restrict movement the most. A% *LA2$(*. +onsider a patient with pain in the front of the upper right thigh one third of the way to the knee. &rom the pain pattern the muscles most likely harboring trigger points are the psoas and the vastus intermedius . (%ote that although the pain reported is on top of the rectus femoris rather than on the psoas or vastus intermedius, the rectus femoris is not a likely candidate because it typically refers pain to the knee). .ange of motion testing usually gives a good indication whether the psoas or the vastus intermedius is the more likely source of pain. Thus if the patient cannot lunge well forward on his left leg while keeping the torso erect there is probably a restriction in the right psoas. If, while lying on the back with a bent right knee the right heel cannot be brought back to the buttock the vastus intermedius may harbor trigger points. 1f course the tests could show restricted motion in both muscles. This simplified e#ample illustrates how muscle testing usually gives crucial clues as to trigger point location. In actual practice the testing would probably begin with an assessment of the patient3s hip alignment and would test psoas range of motion using a more!difficult!to!describe position. -ut the e#ample illustrates how a trigger point therapist uses knowledge of body mechanics and normal ranges of motion in his detective work.

&.12 $A($ATI1%. $alpation is one of the more difficult skills to master. It3s one thing to point to a muscle in a diagram and 4uite another to locate it in a living body with your fingers !! especially if it is not right on the surface, or is surrounded by many others. Then there is the further task of identifying the taut band and the trigger point. 1nce located, pressure directly on a trigger point gives a final clue by producing an intense local sensation. This stimulation may also cause a 4uick muscle twitch, and may reproduce the patient3s pain or other symptom. These signs tell the therapist that he or she is at the source, or one of the sources, of the problem.

&.12 T8* $ATI*%T 8I0T1./. 2ost therapists take the patient3s history at the outset. Dhile the pain pattern and range of motion restrictions reliably indicate trigger point location, more information may be needed. 0ometimes the most important trigger point remains elusive. &or

e#ample, the patient may complain of pain in the back and arm, but his history shows that the accident probably caused a side!bending neck injury, indicating that treatment might be better begun with scalene or other neck muscles. The therapist thus could combine the history of neck injury with knowledge that trigger points in scalene muscles can entrap the brachial nerve ple#us by compressing it directly, or by elevating the first rib, thereby compressing it indirectly. *ither way the scalenes are a possible cause of the shoulder and arm pain, and the detective work has been greatly assisted by knowing the patient3s history. Top of $age 812*

1. E IMINATING TRIGGER POINTS. Trigger points can be eliminated by a variety of techni4ues, including certain kinds of manual pressure, speciali"ed stretching techni4ues sometimes including the use of cold spray, injection, dry needling and others. )avid 0imons 2), ?anet Travell3s co!author, provides an up!to!date review of the most effective manual methods, including important variations on the pressure release and stretching themes (ABBA). .*M'I.*0 A++'.A+/. :nowledgeable physicians can treat trigger points by injection. Injections in e#pert hands can provide lasting relief, but not all physicians who inject for myofascial pain know where the trigger points are, a fact I have ascertained many times talking to my patients. +ertain trigger points are too dangerous to inject, e.g., those over the lung area. 2anual techni4ues have the added advantage that many trigger points in different muscles can be treated in one session. I0 (A-1.!I%T*%0I,*. Trigger point therapy takes time and in this sense is labor intensive. The front!line health care system often cannot allocate enough time to any one patient to treat myofascial pain successfully, a gap which can be filled by non!physician therapists who can allocate more time to the individual. In chronic pain syndromes in particular, time must be taken to ferret out the underlying key trigger points, and further time must be spent reviewing stretching routines and figuring out life!style changes that may be necessary to finally end the pain.

2. PERPETUATING FA#TORS. I& IT )1*0%3T D1.: T8*.* 2'0T -* A .*A01%. After )r. Travell3s research and clinical work had convinced her how widespread trigger point pain was, and how effective the treatments were, she began to teach others. 0he would speak before groups and do demonstrations on pain patients she had never seen before, apparently with skilled showmanship. )r. )avid 0imons reported that on one occasion, when asked afterward how the demonstration went, she replied with a sense of spiritual reverence 3the magic never fails3 (0imons ABBC). A corollary to her conviction about the effectiveness of trigger point work is that if the treatment was not effective then there must be a reason. This reason was usually a perpetuating factor. 0imons goes on to report that in her practice, 0he looked under every physical and medical stone imaginable until she found why that patient had failed to respond to treatment as e#pected. The answers ranged from relatively short upper arms or leg!length discrepancies to inade4uate vitamin intake.

012* *LA2$(*0 can illustrate factors that perpetuate myofascial pain. The history of a patient with long!standing pain may reveal that the person never eats vegetables or takes vitamins. The therapist would suspect that folate deficiency is helping perpetuate the pain (Travell and 0imons ;<<<, ,ol.;=;<5fl). 1r the therapist may notice that a patient with chronic pain in the lower back has unusually short arms. 0hort arms can cause a person to habitually slump forward or sideways because elbows don3t reach the arms of chairs or surface of desks, thereby perpetuating the lower back pain. The patient may be an avid reader who always adopts a slumped position, thereby perpetuating trigger point pain in the neck and shoulder. +omputer work with poor posture likewise takes a toll. A% *00*%TIA( $A.T 1& T8* T8*.A$I0T30 D1.:. Travell and 0imons3 two!volume trigger point manual provides a chapter for each muscle. *ach chapter discusses what factors in a person3s body configuration, posture or living habits can perpetuate trigger point pain in that muscle. The doctors unearthed scores of factors that can perpetuate trigger points. Though not always easy to ferret out, identifying the perpetuating factors is often the key to ultimate success in treatment, so a good trigger point therapist pays close attention them. In sum, an important part of the therapist3s training is identifying perpetuating factors and helping patients understand and deal with them. Top of $age 812*

W"!t3s In ! Wor4?
MANY TERMS. 1ver the course of the last ;6B years a number of astute physicians have published information about patients with pain that seemed to arise in soft tissue but which they couldn3t e#plain. They coined a variety of terms for what they observed, including fibrositis , muskelhaerten , myofascial pain syndrome , myofascitis , myogeloses , nonarticular rheumatism , osteochondrosis , soft tissue rheumatism and tendomyopathy . (Travell and 0imons ;<<< ,ol.;=;5!;<) This list of different terms for the same thing is not e#haustive. Terminological confusion contributed to the difficulty of investigating this muscle!based pain that e#hibits no organic lesion. The various clinical observations about pain caused by muscle tender points were scattered throughout decades of medical literature, in journals serving different specialities, and using various different terms for the condition.

A #OMPREHENSI$E &EFINITION. Travell and 0imons3 work provides a systematic treatment of this soft tissue pain condition. They defined it comprehensively, and the names they adopted for the condition and its cause, myofascial pain and trigger point , respectively, fairly 4uickly superceded the various other terms used historically. It3s now established knowledge that this commonly occurring pain condition ( myofascial pain ) arises specifically in muscle tissue, that a muscle with this condition has an area of compressed sarcomeres at the point where the motor nerve enters the muscle fiber, that this compressed area forms a highly sensitive nodule, that as a result of the compressed area the muscle fiber as a whole becomes taut, and that this sensitive nodule (the trigger point) fre4uently refers pain to other locations in the body in a characteristic pattern.

NEW FO#US. 8istorically speaking, myofascial pain syndrome was difficult to understand because trigger points usually refer pain elsewhere in the body, and because pain they cause can mas4uerade as pain from other tissues (including viscera). The fact that clinicians gave different names to the entity they were trying to describe may have kept them from reali"ing they were studying the same syndrome that others in different specialities had worked on. 0o an important part of Travell and 0imons3 achievement is simply that the medical community now agrees to call this condition moyfascial trigger point pain . Dith this focus, effective, coordinated research can proceed. $erhaps a new medical speciality will evolve with muscle tissue as its subject. 2uscles, after all, make up 6B7 of the body, cause much pain, and deserve attention.

THE TERM 5MYOFAS#IA 5. 2yo refers to muscle and fascial refers to fascia. &ascia is the connective tissue that surrounds all structures of the body, including muscles, organs, bones, nerves, etc. 2uscles attach to bones and other structures by tendons located at the ends of muscles where the fascia surrounding and permeating the muscle becomes thick and strong and connects with the fascia surrounding the bone in 4uestion. Tendons can become tense and develop their own tender points in response to trigger points in the muscle. +onversely, trigger point pain may in some cases be aggravated and perhaps caused by unhealthy fascia. &ascia is unhealthy when it has become immobile, too fibrotic andKor adhered to other structures. In this state it ties down the related muscles and otherwise limits their mobility. $roblems in the fascia can normally be relieved by accurate bodywork that stretches fascia and helps bring moisture and fle#ibility back.

At the 1ctober ABBF &irst International &ascia .esearch +ongress in -oston several papers reported research showing that fascia fre4uently has contractile properties of its own ( 0chleip et.al.ABBFN &ournie ABBF) . 0ome researchers suggested that fascia may assist with movement because of its springy 4uality (Oorn et.al. ABBF). The propriosensory role of 9olgi tendon organs has been understood for a long time. (9olgi are tiny sensory cells in tendons that provide feedback when the tendon is stretched too tightly, feedback that can cause the nervous system to inhibit the muscle3s action.) &ascia is no longer viewed as something that just links or protects other tissues, but as an active system whose role needs much more research.

IST NOT E6HAUSTI$E7 In an instructive e#ample, a physician named Adler wrote in ;<BB about a pain condition originating in muscle in which a hardened tender point develops that fre4uently refers pain elsewhere. 8e named the condition muscular rheumatism (Adler ;<BB). 8e went on to complain= -ut notwithstanding all that has been said and written about these things ... the great majority of practitioners have kept entirely aloof and have persistently ignored all advance in this direction. Dith some practice in palpating muscles, and after attention has once been directed to these muscular lesions, it is not very difficult to convince one3s self of the e#istence of these infiltrations, indurations and swellings in every case of muscular rheumatism. (Adler ;<BB, ,6F!;C=6CB)

SAR#OMERES7 1n microscopic e#amination muscle fibers have a striated appearance, with tiny lines perpendicular to the fiber all along its length. The muscle tissue between two of these tiny lines is a sarcomere. The sarcomere is the basic contractile unit of muscle tissue.

PROPRIOSENSORY7 The ability of the body to sense various conditions within itself.

T"e E8o)ution of Trigger Point T"er!*+

D8I+8 2*)I+A( 0$*+IA(T/ T.*AT0 T.I99*. $1I%T $AI%G 2any people I see have already been to a number of medical specialists, often including a pain specialist. 1ne of these would likely have resolved the person3s pain problem if it fell clearly within his or her area of e#pertise. $art of the reason physicians did not successfully treat these pain problems may be the way medicine is currently organi"ed= in spite of the fact that 6B7 of the body is muscle, no medical specialty claims muscle tissue as it3s subject matter. 'ntil the first edition of Travell and 0imons3 groundbreaking work came out in ;<5C there was no source physicians could turn to to learn how common myofascial pain is, how many other conditions it mimics, and how to treat it. A trigger point is a verfiable organic condition, but it cannot be detected by the instruments a physician typically has in his office. If the pain the patient describes doesn3t stem from an organic problem detected through the usual methods the physician may think it is sciatica, arthritis, tendonitis, bursitis or some other 3!itis3 that is difficult to verify. 1ccasionally trigger point pain is identified as psychosomatic, which can be very discouraging to the patient. Trigger point pain has been something of an enigma, so much so that the term 3enigmatic pain3 is also sometimes applied to it.

T8* *&&1.T T1 '%)*.0TA%) 2/1&A0+IA( $AI%. $rior to ;<EB there were scattered efforts by physicians to understand muscle tender points and referred pain. .esearch broadened and became more systematic in the middle of the twentieth century, particularly through the work of ?anet Travell 2). 0he later entered a productive decades!long cooperation with )avid 0imons 2) and together they produced the systematic work Myofascial 'ain and -ysfunction. An interesting footnote to this history is that )r. Travell served as the Dhite 8ouse physician under $residents :ennedy and ?ohnson. Travell3s trigger point work was the only therapy :ennedy could find to alleviate his severe back pain. )r. 0imons was originally a %A0A &light 0urgeon who had distinguished himself earlier by being the first man into space (in a balloon).

%1%!$8/0I+IA% -*+12*0 I%,1(,*). A few years prior to the publication of the first edition of Travell and 0imons3 te#t a woman named -onnie $rudden published a useful do!it!yourself book entitled 'ain +rasure. $rudden, who enjoyed close working relationships with doctors, was not a physician herself. Though her book presents a simplified L marks the spot version of what Travell and 0imons showed to be a much more comple# topic, she nevertheless helped many people reduce their pain. T8* )I0+1,*./ 1& 2A%'A( $.*00'.*. $rudden3s first encounter with a trigger point came while on a hike with )r. 8ans :rauss. 8e s4uashed a lump on her neck to relieve painful stiffness. 8is treatment was painful (probably unnecessarily painful), but it worked. Then she met )r. Travell who was developing the new discipline of myofascial medicine and treating myofascial pain using injections and cold spray. $rudden worked with doctors to provide e#ercises after operations or trigger point injections. 0he eventually learned to find trigger points herself and began to mark the spots for the doctor to inject. 0he describes how one day she accidentally discovered that the manual pressure techni4ue )r. :raus had used on her neck could relieve pain from muscle trigger points all over the body= P2y ne#t appointment was with a woman who had a painful tennis elbow. 1rdinarily I would have tried to improve the range of the joint with resistance e#ercises. This time I didn3t. I warned her that trigger points are very tender and I sought them as though she were being mapped for injection. -ut instead of marking the arm I held the trigger point. It was painful. Instead of settling for one trigger point I probed up and down the entire arm, pressing trigger points as I found them. In about ;6 minutes there was no pain, and both elbow and shoulder had full range of movement. I really was onto something importantQ PAs soon as the patient left, I raced for the phone and called Dashington to tell )r. Travell about my e#citing discovery.... PIn my 2yotherapy Institute, we worked at first mainly with backs. Instead of taking weeks to get rid of pain with e#ercise and injections, it was taking only a few sessions, often only one. Arm pain, shoulder and neck pain, all surrendered. De even had several stroke patients who were being given stretch and strengthening e#ercises. Two of them had severely contracted arm muscles. 0oon they too were free of pain and their limbs of contracture.P ($rudden - ;<5B $6.) At one point -onnie $rudden became a patient of )r. Travell. 2anual trigger point therapists have since learned that the most effective pressure to use in treating trigger points is less than the level that creates unpleasant discomfort.

T8* $.1&*00I1% 1& T.I99*. $1I%T T8*.A$I0T was founded by non!physicians who were personally influenced by -onnie $rudden and )r. Travell. The training involves anatomy, physiology and palpation training and careful study of Travell and 0imons3 Myofascial 'ain and -ysfunction. 1ther te#ts are used as well, depending on the school. 2anual trigger point therapists help fill a gap in our formal system of medical education and practice. Treatment of the vast numbers of people suffering from myofascial pain is not as yet being ade4uately provided by the traditional medical professions. -eyond this fact, in many cases treatment of this condition by manual techni4ues is preferable even when injection by a knowledgeable doctor is available. It is difficult for the physician to needle all of the dysfunctional

fibers without causing the patient considerable discomfort. 0ometimes he or she has to poke around to find the spot causing the pain. In addition there are important muscles so near the lungs or other vital organs that it can be dangerous to inject them. A manual therapist also has the advantage of not having to stop after treating just a few trigger points. 8e or she can treat many in one session when this is appropriate. Injections in skilled hands can be 4uite effective, but this form of trigger point therapy has limitations and need not be relied on e#clusively when less invasive options are available.
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Trigger Point S9reening %efore Surger+

2yofascial pain caused by trigger points is very common and often mimics more serious conditions. -ecause trigger points are relatively easy to diagnose and treat, screening for myofascial pain should be performed before musculo!skeletal surgeries are undertaken. If the underlying pain is caused by trigger points in muscle tissue, surgery will not eliminate it. 'nfortunately this screening is almost never done. Travell and 0imons make this point using thoracic outlet syndrome (T10) as an e#ample= ... surgeons are frustrated because only about half of operative interventions for T10 are successful. 0ome are dramatically succcessful and some are disastrously unsuccessful. ...Apparently a piece of the pu""le is missing. The fact that a major contributing cause for the pain and entrapments ! myofascial trigger points!! is commonly overlooked contributes to the confusion and frustration (Travell and 0imons ;<<<= ,.;=6;<)R.

About Trigger Points Stiffness from !tent TPs W"!t #!uses Trigger Points? Ho' #ommon is Tr. Point P!in? Wi)) Trigger Point T"er!*+ He)* 'it" Your P!in? Ho' &oes TrP T"er!*+ Wor/? W"!t3s in ! Wor4? E8o)ution of Trigger Point T"er!*+

Trigger Point S9reening %efore Surger+ o9!te ! Pr!9titioner Referen9es

M+ P!in M!n!gement Pr!9ti9e #ont!9t

This page is part of a larger website intended to educate people about trigger point bodywork and other methods of non-invasive, drug-free pain relief. Myofascial therapy was developed by

Ho' I got In8o)8e4 in !)) T"is

physicians in the last few decades. Its primary purpose is to eliminate myofascial pain, but it also improves movement and posture. I offer myofascial treatment and pain management services for the .ackettstown, .opatcong, Mount %reedom and (ashington area of northern "#, though I am not immediately nearby. If you live in a town such as !reen &illage, Mine .ill, $andolph or "ew &ernon "# I would still be the closest certified therapist. Mill Brook, Tabor and &ictory !ardens "# also fall into this category, and much of the rest of "ew #ersey. )omewhat distant towns are mentioned because I have seen many times that people are glad to travel even several hours to get rid of pain. If you live elsewhere you may be able to find a practitioner nearby.

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Travell and 0imons3 two!volume trigger point manual

Pain Categories - Other Types of Pain

Other Types of Pain

Wind-up Pain
Nerve fibers that transmit painful impulses to the brain become "trained" to deliver pain signals after receptors in the back part of the spinal cord are bombarded with pain for an extended period of time These receptors can cause a marked increase in the amount of pain transmitted to the brain Changes in these receptors can also inhibit the efficacy of opioids

Mixed Pain
!oth nociceptive and neuropathic mechanisms are thought to operate in chronic sciatica "ince different pain-generating mechanisms possibly underlie sciatic pain# the term $ixed Pain "yndrome was established

Breakthrough Pain
!reakthrough pain# also known as episodic pain# is pain that %breaks through& a regular pain medicine schedule !reakthrough pain generally falls within three classifications' incident# endof-dose failure# and spontaneous Temporal features# including the onset# duration and

fre(uency of each episode# characteri)e breakthrough pain *esearchers estimate that up to +,- of chronic pain suffers on long-acting medication experience breakthrough pain ./ Pain can occur even through a patient is adhering to the medication schedule and is taking the correct dose of pain medication 0pisodes of breakthrough pain may be spontaneous# occurring without a precipitated event# or initiated by a volitional or nonvolitional event .1 2hile the fre(uency of breakthrough pain reported in the literature is somewhat variable# it is generally accepted that patients will experience one to four episodes per day .3# .4# .,# ..# .+ 5n one key study# the median number of breakthrough pain incidents over a /3-hour period was four# with 6/ patients experiencing seven or more breakthrough pain episodes during that period .7 8orty-three percent of the pain episodes had an onset within three minutes# and the median duration of the pains was 19 minutes :range 6-/39 minutes; +9 !reakthrough pain is more common in the cancer patient population <bout one-half to twothirds of patients with chronic cancer-related pain also experience episodes of breakthrough cancer pain +6 5n one study# +/ the 46 breakthrough pain episodes reported by patients were analy)ed by their defining characteristics The ma=ority were found to be related to the tumor and located at the same site as the continuous pain# suggesting that the breakthrough pain was most likely an exacerbation of the existing pain

Visceral Pain
>isceral pain is defined as pain that originates from deep visceral structures and can be identified by location :e g # abdomen; +1 and by pain features :e g # dull# cramping; +3# +4 *elatively minor lesions in viscera such as the stomach# the bladder or the ureters can produce excruciating pain $any diseases of the liver# the lungs or the kidneys are completely painless and the only symptoms felt by the patient are those derived from the abnormal functioning of these organs +,# +.

Referred Pain
*eferred Pain is felt at a site other than where the cause is situated <n example is the pain from the pancreas# which is felt in the back Pain in internal organs is often referred to sites distant from the organs themselves# such as gall bladder pain# which is felt in the back

Psychogenic Pain
Psychogenic pain is a pain disorder associated with psychological factors 5ts main feature is a persistent complaint of pain in the absence of organic disease and with evidence of a psychological cause "ome types of mental or emotional problems can cause# increase# or prolong pain ?eadaches# muscle pains# back pain# and stomach pains are some of the most common types of psychogenic pain The pattern of pain may not conform to the known anatomic distribution of the nervous system

Some

isease-specific !hronic Pain !onditions

Osteoarthritis *heumatoid <rthritis 8ibromyalgia "ickle Cell Pain

Pain Categories - Neuropathic Pain

"europathic Pain

"europathic Pain O#er#ie$ % &nimation

Causes and effects of neuropathic pain "elect format' :"ilverlight "mooth "treaming; :"ilverlight - 2$>; :2indow $edia Player @ 2$>; Pathophysiology of "europathic Pain % &nimation

Principle types of pathophysiologies related to neuropathic pain "elect format' :"ilverlight "mooth "treaming; :"ilverlight - 2$>; :2indow $edia Player @ 2$>; Neuropathic pain involves in=ury or alteration of the normal sensory and modulatory nervous systems Painful neuropathies can result from a broad range of etiologies# including'4. $etabolic and endocrinologic disorders such as diabetes and liver disease# infection# demyelinating disorders# stroke and spinal cord in=uries# malignancies# and other causes These changes can produce a set of neuropathic symptoms that are often difficult to treat 4+ $ultiple changes may occur in the in=ured neural structures "uch changes may include' abnormal nerve regeneration# disinhibition of modulatory processes# and decreased expression of muopioid receptors Changes may also occur in areas not directly in=ured A often distant from the original insult 47# ,9 The resulting pain complaints include spontaneous %burning& sensations# with intermittent sharp# lightening-like stabbing and shooting pain ,6 $arked sensitivity and pain may be elicited by minimal stimulation such as a light touch# a slight bree)e# or a temperature

change ,/ Treatment of neuropathic pain can be a challenge "ymptoms vary among patients and may be resistant to common analgesics ?owever# most patients will experience satisfactory pain relief and improved (uality of life after appropriate therapy ,1

Pathophysiologies
$ultiple processes are capable of producing sufficient neural alteration to produce neuropathic pain ,3 These processes include' <bnormal nerve regeneration 5ncreased expression of membrane sodium channels Bisinhibition of modulatory processes Becreased expression of mu-opioid receptors

&'normal ner#e regeneration

<bnormal nerve regeneration may occur following peripheral nerve damage Aleading to the formation of a neuroma at the nerve trunk These nerve sprouts can generate spontaneous discharge leading to a sensation of pain ,4# ,,

(ncreased expression of mem'rane sodium channels

5ncreased expression of membrane sodium channels within axons of damaged nerves is also believed to underlie ectopic impulse generation after peripheral nerve in=ury 3 The accumulation of sodium channels lowers the threshold of activation Afacilitating repetitive firing of the in=ured neurons and generating the sensation of pain 3

isinhi'ition
Coss of inhibitory mechanisms following peripheral nerve in=ury can also lead to hypersensitivity and pain ,. < substantial loss of D<!<-mediated inhibition occurs after peripheral nerve in=ury due to selective death of D<!<-ergic neurons in the dorsal horn of the spinal cord leading to an inability for normal inhibition of pain signals# thus lowering the perceived threshold of pain ,+

ecreased expression of mu-opioid receptors

Becreased expression of mu-opioid receptors in dorsal root ganglion neurons and spinal neurons can contribute to disinhibition after peripheral nerve in=ury ,7 This down-regulation of opioid receptors corroborates with the attenuation of the effects of opioids or other analgesics in neuropathic pain management .9 0tiologies of Painful Neuropathies.6 Meta'olic and )ndocrinologic isorders

Biabetes Civer disease *enal dysfunction and hemodialysis ?ypothyroidism <cromegaly

(nfection ?5> >arcella )oster virus ?epatitis ! and C ?uman T-cell lymphotrophic virus :?TC>-6; Cyme disease Ceprosy

emyelinating

isorders

Duillain-!arreE syndrome $ultiple "clerosis Chronic inflammatory demyelinating polyneuropathy

Stroke and Spinal !ord (n*uries Malignancies )ntrapment &utoimmune and +ranulomatous isorders

"=ogrenEs syndrome "ystemic lupus erythmatosus *heumatoid arthritis "arcoidosis Polyarteritis nodosa Churg-"trauss vasculitis 2egenerEs granulomatosis Diant cell or temporal arteritis

(mmunoglo'ulinemias $onoclonan :$; proteins <myloidosis Cryoglobinemia

ietary and &'sorption &'normalities <lcoholic neuropathy !6/# thiamine and other vitamin deficiencies

Toxic "europathies

?eavy metals Chemotherapy

,ereditary "europathies Charcot-$arie-Tooth 8abryEs disease 8amilial amyloid polyneuropathy Porphyria

!ryptogenic "europathies 5diopathic Complex regional pain syndromes 0ssential trigeminal and glossopharyngeal neuralgias

"ocicepti#e Reception and Transmission

"ocicepti#e Pain O#er#ie$ % &nimation

The physiology of nociceptive pain transduction# conduction# transmission# perception and modulation "elect format' :"ilverlight smooth streaming; :"ilverlight - 2$>; :2indow $edia Player @ 2$>; Nociceptive pain occurs as a result of the activation of the nociceptive system by noxious stimuli# inflammation or disease 39# 36 The neurophysiologic underpinnings of pain can be divided into four stages' transduction# transmission# pain modulation# and perception 3/ <t every point in the process# the intensity and propagation of pain

signals can be either inhibited or facilitated by neural pathways originating in the brain This capacity to modulate signaling may account# in part# for wide variations in pain perception among different individuals who sustain the same in=ury 31

Transduction
Transduction occurs when a stimulus# such as pressure# thermal energy# or chemical irritation# is converted into a nerve signal :e g # an action potential; This occurs at the ends of sensory nerve cells whose terminals are sensitive to this type of activation 33 These cells# known as nociceptors# are distributed throughout the body 34

Transmission
Transmission is the process of transferring pain information from the peripheral to the central nervous system 3, "ignals are transmitted along the axons of nociceptors These smalldiameter nerve fibers comprise two main types' unmyelinated C-fibers# which conduct impulses slowly :F9 4@/ mGsec;# and thinly myelinated <-delta fibers# which carry impulses at a faster rate :F4@19 mGsec; 3.# 3+ $ost primary sensory nerve fibers# including nociceptors# synapse with second-order neurons in the dorsal horn of the spinal cord 8rom here# pro=ection neurons carry information to the brainstem# thalamus# and hypothalamus# as well as to reflex arcs to mediate an avoidance response 37

Modulation
Pain modulation refers to the transmission of pain signals through the dorsal horn 49 $any of these signals never reach consciousness because they are dampened by intrinsic modulatory activity within the central nervous system 46 The gate control theory# advanced by $el)ack and 2all in 67,/# focused on descending pathways from the brain to the spinal cord that inhibited pain signaling 4/ The current view is that signals originating in the brain can both inhibit and facilitate pain signal transmission 41 Neurotransmitters involved in these pathways include endogenous opiates :enkephalins# dynorphins# beta-endorphins;# 43 serotonin# and norepinephrine

Perception
Perception of pain is the awarenessAtypically an uncomfortable awarenessAassociated with a specific area of the body 5t depends on the transmission of pain signals through the thalamus to the cortex and limbic system 44 <t this point in pain processing# perception of the pain experience is influenced by social and environmental cues# as well as by cultural conditioning and past personal experiences 4,

Some )tiologies of "ocicepti#e Pain

$usculoskeletal 5n=uries Tissue Bamage Post-surgical Nociceptive Pain Cancer-related Nociceptive Pain $yofascial Pain "yndrome

Dictionary: referred pain null

Home > Library > Literature & Language > Dictionary (r-frd') n. ain t!at i" felt in a part of t!e body at a di"tance from t!e area of pat!ology# a" pain in t!e rig!t "!oulder deri$ed from t!e pre"ence of a gall"tone in t!e bladder% Home > Library > Healt! > &port" &cience and 'edicine "ynalgia ain felt in an undamaged part of t!e body a(ay from t!e actual point of in)ury or di"ea"e% *t may be a $i"ceral (abdominal organ) pain# (!ic! i" percei$ed a" originating in t!e body (all due to ner$e impul"e" from $i"ceral pain receptor" tra$elling along t!e "ame pat!(ay a" "omatic pain impul"e"# or t!e pain may ari"e in body (all "tructure" and be referred di"tally% Degenerati$e c!ange" in cer$ical $ertebrae# for e+ample# can cau"e tendiniti"-li,e pain in t!e elbo(# and degeneration of lumbar facet" can cau"e calf pain% &ee al"o radicular pain# "omatic pain% null -i,ipedia:
Referred pain

.op Home > Library > 'i"cellaneou" > -i,ipedia Referred pain ("ometime" referred to a" reflective pain/01) i" a term u"ed to de"cribe t!e p!enomenon of pain percei$ed at a "ite ad)acent to or at a di"tance from t!e "ite of an in)ury'" origin%/21 3ne of t!e be"t e+ample" of t!i" i" during i"c!emia broug!t on by a myocardial infarction (!eart attac,) (!ere pain i" often felt in t!e nec,# "!oulder"# and bac, rat!er t!an in t!e c!e"t# t!e "ite of t!e in)ury% .!e *nternational 4""ociation for t!e &tudy of ain# a" of 2550# !a" not officially defined t!e term6 !ence "e$eral aut!or" !a$e defined t!e term differently% !y"ician" and "cienti"t" !a$e ,no(n about referred pain "ince t!e late 0775"% De"pite an increa"ing amount of literature on t!e "ub)ect# t!e mec!ani"m of referred pain i" un,no(n# alt!oug! t!ere are "e$eral t!eorie"% 8ontent" /!ide1 0 8!aracteri"tic" 2 'ec!ani"m o 2%0 8on$ergent-pro)ection o 2%2 8on$ergence-facilitation o 2%9 4+on-refle+ o 2%: Hypere+citability o 2%; .!alamic-con$ergence 9 <+ample"

: Laboratory te"ting met!od" o :%0 4lgogenic "ub"tance" o :%2 ="ing electrical "timulation ; ="e in 8linical Diagno"i" and .reatment" o ;%0 3rt!opedic Diagno"i" o ;%2 >eneral Diagno"i" ? @eference"
Characteristics

.!e "iAe of referred pain i" related to t!e inten"ity and duration of ongoingBe$o,ed pain%/01 .emporal "ummation i" a potent mec!ani"m for generation of referred mu"cle pain%/01 8entral !ypere+citability i" important for t!e e+tent of referred pain%/01 atient" (it! c!ronic mu"culo",eletal pain" !a$e enlarged referred pain area" to e+perimental "timuli%/vague1 .!e pro+imal "pread of referred mu"cle pain i" "een in patient" (it! c!ronic mu"culo",eletal pain and $ery "eldom i" it "een in !ealt!y indi$idual"%/01 'odality-"pecific "omato"en"ory c!ange" occur in referred area"# (!ic! emp!a"iAe t!e importance of u"ing a multimodal "en"ory te"t regime for a""e""ment%/01
Mechanism

.!ere are "e$eral propo"ed mec!ani"m" for referred pain% 8urrently t!ere i" no definiti$e con"en"u" regarding (!ic! t!eory may be correct% .!e cardiac general $i"ceral "en"ory pain fiber" follo( t!e "ympat!etic" bac, to t!e "pinal cord and !a$e t!eir cell bodie" located in t!oracic dor"al root ganglia 0-:(;)% 4" a general rule# in t!e t!ora+ and abdomen# >C4 pain fiber" follo( "ympat!etic fiber" bac, to t!e "ame "pinal cord "egment" t!at ga$e ri"e to t!e preganglionic"ympat!etic fiber"% .!e central ner$ou" "y"tem (8D&) percei$e" pain from t!e !eart a" coming from t!e "omatic portion of t!e body "upplied by t!e t!oracic "pinal cord "egment" 0-:(;)% 4l"o# t!e dermatome" of t!i" region of t!e body (all and upper limb !a$e t!eir neuronal cell bodie" in t!e "ame dor"al root ganglia (.0-;) and "ynap"e in t!e "ame "econd order neuron" in t!e "pinal cord "egment" (.0-;) a" t!e general $i"ceral "en"ory fiber" from t!e !eart% .!e 8D& doe" not clearly di"cern (!et!er t!e pain i" coming from t!e body (all or from t!e $i"cera# but it percei$e" t!e pain a" coming from "ome(!ere on t!e body (all# i%e% "ub"ternal pain# left armB!and pain# )a( pain%

Convergent-projection
.!i" repre"ent" one of t!e earlie"t t!eorie" on t!e "ub)ect of referred pain% *t i" ba"ed on t!e (or, of -%4% &turge and E% @o"" from 0777 and later .8 @uc! in 0F?0% .!i" t!eory propo"e" t!at afferent ner$e fiber" from ti""ue" con$erge onto t!e "ame "pinal neuron%

.!i" t!eory e+plain" (!y referred pain i" belie$ed to be "egmented in muc! t!e "ame (ay a" t!e "pinal cord% 4dditionally# e+perimental e$idence "!o(" t!at (!en local pain (pain at t!e "ite of "timulation) i" inten"ified t!e referred pain i" inten"ified a" (ell% 8ritici"m of t!i" model ari"e" from it" inability to e+plain (!y t!ere i" a delay bet(een t!e on"et of referred pain after local pain "timulation% <+perimental e$idence al"o "!o(" t!at referred pain i" often unidirectional% Gor e+ample "timulated local pain in t!e anterior tibial mu"cle cau"e" referred pain in t!e $entral portion of t!e an,le6 !o(e$er referred pain mo$ing in t!e oppo"ite direction !a" not been "!o(n e+perimentally% La"tly# t!e t!re"!old for t!e local pain "timulation and t!e referred pain "timulation are different# but according to t!i" model t!ey "!ould bot! be t!e "ame%/01

Convergence-facilitation
*n 07F9 E 'acHenAie created an alternate t!eory ba"ed on t!e idea" of &turge and @o""% He belie$ed t!at t!e internal organ" (ere in"en"iti$e to "timuli% Gurt!ermore# !e belie$ed t!at nonnocicepti$e afferent input" to t!e "pinal cord created (!at !e termed Ian irritable focu"I% .!i" focu" cau"ed "ome "timuli to be percei$ed a" referred pain% Ho(e$er# t!e t!eory did not gain (ide"pread acceptance from critic" due to it" di"mi""al of $i"ceral pain% @ecently t!i" "imple idea !a" regained "ome credibility under a ne( term# central "en"itiAation% .!i" t!eory# t!erefore# e+plain" (!y c!ange" in "omato"en"ory "en"ibility could be undergoing proce""e" "imilar to t!e dor"al !orn and t!e brain"tem% 4dditionally# t!e delay in appearance of referred pain "!o(n in laboratory e+periment" can be e+plained due to t!e time reJuired to create t!e central "en"itiAation%/01

Axon-reflex
.!i" t!eory "ugge"t" t!at t!e afferent fiber i" bifurcated before connecting to t!e dor"al !orn% Kifurcated fiber" do e+i"t in mu"cle# ",in# and inter$ertebral di"c"% Let t!e"e particular neuron" are rare and are not repre"entati$e of t!e (!ole body% 4+on-@efle+ al"o doe" not e+plain t!e time delay before t!e appearance of referred pain# t!re"!old difference" for "timulating local and referred pain# and "omato"en"ory "en"ibility c!ange" in t!e area of referred pain%/01

Hyperexcitability
.!i" t!eory !ypot!e"iAe" t!at referred pain !a" no central mec!ani"m% Ho(e$er# it doe" "ay t!at t!ere i" one central c!aracteri"tic t!at predominate"% .!i" t!eory i" deri$ed from e+periment" in$ol$ing no+iou" "timuli and recording" from t!e dor"al !orn of animal"% <+periment" re$ealed t!at referred pain "en"ation" began minute" after mu"cle "timulation% ain (a" felt in a recepti$e field t!at (a" "ome di"tance a(ay from t!e original recepti$e field% 4ccording to t!e t!eory ne( recepti$e field" are created a" a re"ult of t!e opening of latent con$ergent afferent fiber" in t!e dor"al !orn% .!i" "ignal could t!en be percei$ed a" referred pain%

&e$eral c!aracteri"tic" are in line (it! t!i" t!eory of referred pain "uc! a" dependency on "timulu" and t!e time delay in t!e appearance of referred pain a" compared to local pain% Ho(e$er# t!e appearance of ne( recepti$e field"# (!ic! i" interpreted to be referred pain# conflict" (it! t!e ma)ority of e+perimental e$idence from "tudie" including "tudie" of !ealt!y indi$idual"% Gurt!ermore# referred pain generally appear" (it!in "econd" in !uman" a" oppo"ed to minute" in animal model"% &ome "cienti"t" attribute t!i" to a mec!ani"m or influence do(n"tream in t!e "upra"pinal pat!(ay"% Deuroimaging tec!niJue" "uc! a" <. "can" or f'@* may $i"ualiAe t!e underlying neural proce""ing pat!(ay" re"pon"ible in future te"ting%/01

Thalamic-convergence
.!i" t!eory "ugge"t" t!at referred pain i" percei$ed a" "uc! due to t!e "ummation of neural input" in t!e brain# a" oppo"ed to t!e "pinal cord# from t!e in)ured area and t!e referred area% <+perimental e$idence on t!i" t!eory i" lac,ing% Ho(e$er# pain "tudie" performed on mon,ey" re$ealed "e$eral pat!(ay" con$erging on bot! "ubcortical and cortical neuron"%/01
Examples

Location =pper c!e"tBleft limb Head >eneral @ig!t "!oulder Left "!oulder

escription 'yocardial i"c!aemia (t!e lo"" of blood flo( to a part of t!e !eart mu"cle ti""ue) i" po""ibly t!e be"t ,no(n e+ample of referred pain6 t!e "en"ation can occur in t!e upper c!e"t a" a re"tricted feeling# or a" an ac!e in t!e left "!oulder# arm or e$en !and%/91 M*ce-cream !eadac!eN or Mbrain freeAeN i" anot!er e+ample of referred pain# in (!ic! t!e $agu" ner$e i" cooled by cold in"ide t!e t!roat%/91 !antom limb pain# a type of referred pain# i" t!e "en"ation of pain from a limb t!at !a" been lo"t or from (!ic! a per"on no longer recei$e" p!y"ical "ignal"% *t i" an e+perience almo"t uni$er"ally reported by amputee" and Juadriplegic"%/91 Li$er# gallbladder .!oracic diap!ragm (He!r'" "ign)# lung
Laboratory testing methods

ain i" "tudied in a laboratory "etting due to t!e greater amount of control t!at can be e+erted% Gor e+ample t!e modality# inten"ity# and timing of painful "timuli can be controlled (it! muc! more preci"ion% -it!in t!i" "etting t!ere are t(o main (ay" t!at referred pain i" "tudied%

Algogenic s!bstances

*n recent year" "e$eral different c!emical" !a$e been u"ed to induce referred pain including brady,inen# "ub"tance # cap"aicin#/:1 and "erotonin% Ho(e$er before any of t!e"e "ub"tance" became (ide"pread in t!eir u"e a "olution of !ypertonic "aline (a" u"ed in"tead% .!roug! $ariou" e+periment" it (a" determined t!at t!ere (ere multiple factor" t!at correlated (it! "aline admini"tration "uc! a" infu"ion rate# "aline concentration# pre""ure# and amount of "aline u"ed% .!e mec!ani"m by (!ic! t!e "aline induce" a local and referred pain pair i" un,no(n% &ome re"earc!er" !a$e commented t!at it could be due to o"motic difference"# !o(e$er t!at i" not $erified%/01

"sing electrical stim!lation

*ntramu"cular electrical "timulation (*'<&) of mu"cle ti""ue !a" been u"ed in $ariou" e+perimental and clinical "etting"% .!e ad$antage to u"ing an *'<& "y"tem o$er a "tandard "uc! a" !ypertonic "aline i" t!at *'<& can be turned on and off% .!i" allo(" t!e re"earc!er to e+ert a muc! !ig!er degree of control and preci"ion in term" of t!e "timulu" and t!e mea"urement of t!e re"pon"e% .!e met!od i" ea"ier to carry out t!an t!e in)ection met!od a" it doe" not reJuire "pecial training in !o( it "!ould be u"ed% .!e freJuency of t!e electrical pul"e can al"o be controlled% Gor mo"t "tudie" a freJuency of about 05 HA i" needed to "timulate bot! local and referred pain%/;1 ="ing t!i" met!od it !a" been ob"er$ed t!at "ignificantly !ig!er "timulu" "trengt! i" needed in order to obtain referred pain relati$e to t!e local pain% .!ere i" al"o a "trong correlation bet(een t!e "timulu" inten"ity and t!e inten"ity of referred and local pain% *t i" al"o belie$ed t!at t!i" met!od cau"e" a larger recruitment of nociceptor unit" re"ulting in a "patial "ummation% .!i" "patial "ummation re"ult" in a muc! larger barrage of "ignal" to t!e dor"al !orn and brain"tem neuron"%/01
"se in Clinical iagnosis and Treatments

@eferred pain can be indicati$e of ner$e damage% 4 ca"e "tudy done on a ?9 year old man (it! a "u"tained in)ury during !i" c!ild!ood de$eloped referred pain "ymptom" after !i" face or bac, (a" touc!ed% 4fter e$en a lig!t touc!# t!ere (a" "!ooting pain in !i" arm% .!e "tudy concluded t!at t!e rea"on for t!i" man'" pain (a" po""ibly due to a neural reorganiAation (!ic! "en"itiAed region" of !i" face and bac, after t!e ner$e damage occurred% *t i" mentioned t!at t!i" ca"e i" $ery "imilar to (!at p!antom limb "yndrome patient" "uffer% .!i" conclu"ion (a" ba"ed on e+perimental e$idence gat!ered by C% @amac!andran in 0FF9% -it! t!e difference being t!at t!e arm t!at i" in pain i" "till attac!ed to t!e body%

#rthopedic iagnosis
Grom t!e abo$e e+ample" one can "ee (!y under"tanding of referred pain can lead to better diagno"e" of $ariou" condition" and di"ea"e"% *n 0F70 p!y"iot!erapi"t @obin 'cHenAie de"cribed (!at !e termed centraliAation% He concluded t!at centraliAation occur" (!en referred pain mo$e" from a di"tal to a more pro+imal location% 3b"er$ation" in "upport of t!i" idea (ere "een (!en patient" (ould bend bac,(ard and for(ard during

an e+amination% &tudie" !a$e reported t!at t!e ma)ority of patient" t!at centraliAed (ere able to a$oid "pinal "urgery due to i"olation of t!e area of local pain% Ho(e$er# t!e patient" t!at did not centraliAe !ad to undergo "urgery in order diagno"e and correct problem"% 4" a re"ult of t!i" "tudy t!ere !a" been a lot of re"earc! into t!e elimination of referred pain t!roug! certain body mo$ement"% 3ne e+ample of t!i" i" referred pain in t!e calf% 'cHenAie "!o(ed t!at t!e referred pain (ould mo$e clo"er to t!e "pine (!en t!e patient bent bac,(ard" in full e+ten"ion a fe( time"% 'ore importantly# t!e referred pain (ould di""ipate e$en after t!e mo$ement" (ere "topped%/?1

$eneral iagnosis
4" (it! myocardial i"c!aemia referred pain in a certain portion of t!e body can lead to a diagno"i" of t!e correct local center% &omatic mapping of referred pain and t!e corre"ponding local center" !a" led to $ariou" topograp!ic map" being produced in order to aid in pinpointing t!e location of pain ba"ed on t!e referred area"% Gor e+ample local pain "timulated in t!e e"op!agu" i" capable of producing referred pain in t!e upper abdomen# t!e obliJue mu"cle"# and t!e t!roat% Local pain in t!e pro"tate can radiate referred pain to t!e abdomen# lo(er bac,# and calf mu"cle"% Hidney "tone" can cau"e $i"ceral pain in t!e ureter a" t!e "tone i" "lo(ly pa""ed into t!e e+cretory "y"tem% .!i" can cau"e immen"e referred pain in t!e lo(er abdominal (all%/O1 *n addition to t!i"# recent re"earc! !a" found t!at ,etamine# a "edati$e# i" capable of bloc,ing referred pain% .!e "tudy (a" conducted on patient" "uffering from fibromyalgia# a di"ea"e c!aracteriAed by )oint and mu"cle pain and fatigue% .!e"e patient" (ere loo,ed at "pecifically due to t!eir increa"ed "en"iti$ity to nocicepti$e "timuli% Gurt!ermore# referred pain appear" in a different pattern in fibromyalgic patient" t!an it doe" in normal people% 3ften t!i" difference manife"t" a" a difference in term" of t!e area t!at t!e referred pain i" found (di"tal $"% pro+imal) a" compared to t!e local pain% .!e area i" al"o muc! more e+aggerated o(ing to t!e increa"ed "en"iti$ity% /71
References

0% P a b c d e f g h i j k l m 4rendt-Diel"en L# &$en""on (2550)% I@eferred mu"cle pain: ba"ic and clinical finding"I% Clin J Pain %& (0): 00QF% doi:05%05FOB55552;57255059555-55559% '*D 0027F579% 2% ' referred pain at Dorland'" 'edical Dictionary 9% P a b c (255O)% ain and nociception% @etrie$ed Do$ember 27# 255O# from ain and nociception - -i,ipedia# t!e free encyclopedia -eb "ite: !ttp:BBen%(i,ipedia%orgB(i,iB ainRandRnociception :% ' -itting D# &$en""on # >ottrup H# 4rendt-Diel"en L# Een"en .& (2555)% I*ntramu"cular and intradermal in)ection of cap"aicin: a compari"on of local and referred painI% Pain () (2-9): :5OQ02% doi:05%050?B&595:-9F;F(FF)55290-?% '*D 05???;:O% ;% ' Ho"e, <# Han""on (2559)% I erceptual integration of intramu"cular electrical "timulation in t!e focal and t!e referred pain area in !ealt!y !uman"I% Pain %*+ (0-2): 02;Q90% doi:05%050?B&595:-9F;F(59)550O0-:% '*D 0::FF:27%

?% ' Da$i"# Klac,(ood# 8 (255:)% .!e centraliAation p!enomenon: *t" role in t!e a""e""ment and management of lo( bac, pain% K8 'edical Eournal% :?# 9:7-9;2% O% ' ur$e"# D et al% (255:)% Deuro"cience 9rd <dition% &underland# '4: &inauer 4""ociate"# *nc% 7% ' >ra$en-Diel"en# . et al% (0FFF)%Hetamine reduce" mu"cle pain# temporal "ummation# and referred pain in fibromyalgia patient"% ain% 7;# :79-:F0% /!ide1
$SdSe

,ain and nociception

Head and nec, Headac!e - Dec, - 3dynop!agia ("(allo(ing) - 3talgia (ear) - .oot!ac!e .or"o 4bdomen - Kac, (=pper# Lo(er) - 8!e"t - 'a"todynia (Krea"t) - el$ic pain

'u"culo",eletal 4rt!ralgia ()oint) - Kone pain - 'yalgia (mu"cle) Delayed on"et mu"cle "orene"" - 8ongenital in"en"iti$ity to pain H&4D (.ype *# ** congenital "en"ory neuropat!y# *** familial dy"autonomia# *C congenital in"en"iti$ity to pain (it! an!idro"i"# C congenital in"en"iti$ity to pain (it! partial an!idro"i") - Deuralgia - ain a"ymbolia - ain di"order - aro+y"mal e+treme pain di"order 4llodynia - Krea,t!roug! pain - 8!ronic pain - Hyperalge"ia Hypoalge"ia - Hyperpat!ia - !antom pain - Referred pain 8old pre""or te"t - Dolorimeter 4nterolateral "y"tem - ain management (4ne"t!e"ia# 8ordotomy) - ain "cale - ain t!re"!old - ain tolerance - o"teromarginal nucleu" &ub"tance - &uffering - 3 T@&.

3t!er condition"

.e"t" @elated concept"